ML20059B141
| ML20059B141 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 12/20/1993 |
| From: | Link B WISCONSIN ELECTRIC POWER CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| CON-NRC-93-136 VPNPD-93-218, NUDOCS 9401030353 | |
| Download: ML20059B141 (8) | |
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l WISCONSIN' Electnc-
. POWER COMPANY Ii 231 W Mchgort PO. Box 2046. MAvoukee3A 53201-2046 (414)221 2345 -
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.VPNPD-93-218
'NRC-93-136 December 20, 1993 t
I Document Control Desk U.
S.
NUCLEAR REGULATORY COMMISSION Mail Station P1-137 Washington, DC 20555 Centlemen:
Ej DOCKETS 50-266 AND 50-301 REPLY TO A NOTICE OF VIOLATION POINT BEACH NUCLEAR PLANT, UNITS 1 AND-2 i
,On November 18, 1993, the Nuclear Regulatory Commission forwarded.
to Wisconsin Electric Power Company, licensee for.the Point Beach; Nuclear: Plant, the results of a routine safety' inspection.conductedi by Messrs. K. R.
Jury and'J. Gadzala.
This inspection' report included a Notice of Violation (NOV) containing two. Severity' Level IV-violations.
We have reviewed this NOV and, -pursuant to the: provisions'of
.10 CFR.2.201, have prepared.a written response of explanation concerning the identified violations., 0ur' written response.is-included as an attachment to this letter.. Please contact us if there are.any questions or if you. require any additional-information concerning this response.
l-Sincerely,
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Bo ink Vic ' President Nuclear Power Attachment I
cc:
NRC Resident Inspector NRC Regional Administrator
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't RESPONSE TO NOTICE OF VIOLATION Wisconsin Electric Power Company Point Beach Nuclear Plant, Units 1 and 2 g
Docket Nos. 50-266 and 50-301 License Nos. DPR-24 and DPR-27 During a routine safety inspection conducted by Messrs.
K.
R. Jury and J. Gadzala from September 7 through October 25, 1993, two violations of.NRC requirements were identified.
Both identified violations were classified as Severity Level IV.
Inspection Report i
Nos. 50-266/93014(DRP) and 50-301/93014(DRP)-and the' Notice of Violation (NOV) transmitted to Wisconsin Electric on November 18, 1993, provide details regarding these violations.
In accordance with the instructions provided in the NOV, our reply to the alleged violations includes: (1) the reason for the violation, or if contested, the basis for disputing the violation; (2) corrective action taken and results achieved; and (3) corrective action to be taken to avoid further violations; and (4) the date when full compliance will be achieved.
VLQLATION 1:
10 CFR 50, Appendix B, Criterion V,
" Instructions, Procedures'and Drawings," requires in_part, that activities.affecting~ quality shall be prescribed by instructions,_ procedures, or drawings of a l
d type appropriate to the circumstance and be accomplished in accordance with them.
Instructions or procedures shall include appropriate quantitative or. qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished.
Contrary to the above, various work instructions were not appropriate as evidenced by the following examples.
a.
The work' instructions for replacing the bearings of safety injection pump 1P-15A, on April 12, 1993, were not appropriate, in that they did not specify. lubricating the bearings prior to reinstallation, which resulted in the pump catastrophically'failing during its return to service testing, b.
The work instructions for performing electrical distribution system meter calibrations on July 27, 1993, were not appropriate, in that they did not adequately specify appropriate qualitative or quantitative acceptance criteria to ensure that electrical disconnects were properly opened.
c.
The work instructions for performing maintenance on service water isolation valve SW-LW-61-S, on April 15, 1993, and June 16, 1993, were not appropriate, in that they did not ensure proper orientation and configuration of the solenoid,
'which resulted in the valve being. inoperable for 88 days.
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We concur that the events and circumutances described in these three examples do constitute a violation of 10 CFR 50, Appendix B, Criterion V.
1 REASON FOR VIOLATION 1 The event described in example (a) of Violation 1 occurred on April 12, 1993 during the performance of preventive maintenance on safety injection pump motor IP-15A-M.
Preventive Maintenance Task i
Sheet 0045402 was performed in which the oil was drained, the bearings removed, the shaft and bearings measured, and the bearings and oil replaced.
On April 29, 1993, prior to initial criticality, following the completion of the Unit i refueling and maintenance outage, the bearings for IP-15A failed immediately after the pump was started to perform in-service testing.
Foll7 wing the bearing failure, it was determined that the bearings failed because they were inadequately lubricated.
The maintenance electrician responsible for the bearing maintenance stated that, prior to reassembling the motor, he lubricated the shaft but did not lubricate the associated bearing shells.
The failure of the i
bearings necessitated replacing the pump motor.
j Following the event, a Human Performance Enhancement System (HPES) evaluation was performed to determine the contributing factors of the event.
This evaluation concluded that the root cause of the bearing failure was inadequate lubrication.
It also concluded that the preventive maintenance task sheet used during the maintenance contributed to the failures because it did not contain a i
lubrication requirement for the bearings.
Additionally, during the investigation, the maintenance worker who performed the work acknowledged his error and stated that, based on his level of experience, he should have lubricated the bearings.
The event described in example (b) of Violation 1 occurred on j
July 26, 1993, at about 1333 hours0.0154 days <br />0.37 hours <br />0.0022 weeks <br />5.072065e-4 months <br />, with both units atefull power.
A fuse in the Unit 1, B train, 4160V emergency bus 1A-06 metering and relaying circuit blew during calibration of the 1A-06 voltmeter.
The blown fuse caused a 1A-06 undervoltage signal to be 2
generated, causing the normal power supply breaker for 1A-06 to open and deenergize the bus.
The emergency diesel generator G-02 immediately started and reenergized the 1A-06 bus.
The 1A-06 voltmeter was being calibrated when the fuse blew.
The calibration was being performed by two electricians, one from Point Beach and one from the Electrical Testing and Maintenance division of the System Operations Department of Wisconsin Electric.
The written instruction being used was Preventive Maintenance Task Shoot 0048015.
The task sheet requires two sliders to be opened to electrically isolate the 1A-06 voltmeter from the 1A-06 undervoltage protection relays while the voltmeter is being calibrated.
The isolation of the voltmeter and connection of the calibration equipment is performed inside control panel C-02.
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c At about 1330 hours0.0154 days <br />0.369 hours <br />0.0022 weeks <br />5.06065e-4 months <br />, one electrician opened sliders WNA-8 and WNA-9 on Riser 33 inside C-02 to isolate the. voltmeter.
The other electrician verified that the 1A-06 voltmeter was at 0 volts.
This verification showed that the proper voltmeter was being isolated.
This, however, is not a complete verification of the position of both sliders because the voltmeter would read 0 volts even if only one slider were open.
A visible electrical arc appeared when the electrician attempted to connect the test instrument to the isolated side of slider WNA-9.
The electrician immediately suspected that he had created a short circuit and that a fuse had blown in the circuitry.
He immediately informed the Duty Shift Superintendent.
Electrical Maintenance and-Engineering personnel diagnosed and replaced the blown fuse.
It is believed that one of the sliders was not opened complete), to isolate the circuit.
Following the event, an HPES evaluation was performed.
It was determined that this event was caused by a human error by one of the electricians performing calibration of the 1A-06 voltmeter.
A contributing factor to this error was lack of verification of both sliders being open.
All aspects of the event described in example (c) of Violation 1-will be addressed in our response to Violation 2.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED FOR VIOLATION 1:
With respect to example (b), a review of the'4160V. system meter calibration' event and the associated HPES report was performed and a decision was made to have a Point Beach maintenance supervisor i
conduct pre-job briefings with personnel from the Electrical Testing and Maintenance division prior to starting any work at Point Beach (with the exception of work performed outside the security fence).
This pre-job briefing will cover the work scope, plant and system status, work control requirements, and actions for q
problem resolution.
These briefings are now being performed.
With respect to examples (a) and (c), corrective actions are in-progress or planned as described below.
CORRECTIVE ACTION TO BE TAKEN TO AVOID FURTHER VIOLATIONS:
In response co the safety injection pump bearing event, the maintenance callup for the safety injection pumps is being revised.
This callup will be revised to provide adequate guidance to ensure that the maintenance is properly performed.
This callup will be revised by March 15, 1994.
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In order to ensure that the work control documents, for work activities performed by personnel from the Electrical Testing and Maintenance division, provide sufficient guidance, a review of these work control documents (with the exception of documents related to work that is performed outside of the security fence) will be performed.
These documents will be revised, as necessary, to ensure that adequate work controls and work instructions are provided.
This action will be completed by July 1,-1994.
In order to confirm that the events discussed in thissviolation are isolated cases and not a generic concern, we intend to conduct a quality assurance audit of completed MWRs to verify proper closecut review with regard to post-maintenance testing.
The adequacy of~
work plans and their pre-job reviews will also be examined during this audit.
This audit will be completed by February 28, 1994.
DATE WiiEN FULL COMPLIANCE WILL BE ACHIEVED FOR VIOLATION 1:
The revision to the maintenance callup for the safety injection pumps will be completed by March 15, 1994, and the quality assurance audit of completed MWRs will be completed by February 28, 1994.
Additionally, a review of the work control documents for work activities performed by personnel from the Electrical Testing and Maintenance division (except for activities performed out. side of the security fence) and any subsequent document revisions will be completed by July 1, 1994.
Therefore, we will be in full compliance by July 1, 1994.
VIOLATION 2:
Technical Specification 15.3.3.D.1.b requires that all necessary valves required for the functioning of the service water system during accident conditions be operable.
One valve may be out of service for a time not to exceed 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />.
Contrary to the above, on September 10, 1993, service water isolation valve SW-LW-61, which must function during certain accidents, was inoperable for a period of about 88 days.
We concur that the events and circumstances described in this example do constitute a violation of Technical Specification 15.3.3.D.1.b.
REASON FOR VIOLATION 2:
The event described occurred on April 15, 1993.
Corrective a
maintenance was performed to replace the solenoid on SW-LW-61-S, solenoid-operated valve which serves to isolate the instrument air to SW-LW-61, a pneumatically-operated butterfly valve.
SW-LW-61 serves as the service water inlet isolation for each unit's blowdown tank vent condenser, the blowdown evaporator overhead condenser, and the blowdown evaporator distillate cooler.
Following the completion ~of the maintenance, In-Service Test IT-72,
" Service Water Valves (Quarterly)," was performed to verify the valve's operability.
This testing was completed satisfactorily.
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Following the maintenance and subsequent post-maintenance testing,.
a plant engineer inspected the installation and determined that the solenoid had been installed upside down.
The valve supplier specifies that the solenoid should be installed in the upright' 1
position.
Upon discovering the improper orientation of the solenoid, the engineer' initiated a maintenance work request.(MWR) to correct the condition..
The corrective maintenance performed on April 15, 1993, was i
performed by maintenance electricians because of the electrical connections that had to be completed during the installation of the solenoid.
For this reason, the plant engineer discussed the newly-initiated MWR with the electrical maintenance planner.
They.both determined that correcting the orientation of the solenoid would not require any electrical support.
Therefore, the work was scheduled to be performed by maintenance mechanics during the upcoming blowdown evaporator maintenance outage.
On June 14, 1993, the maintenance was performed by two maintenance mechanics.
The MWR stated, in the problem description, " valve mounted in opposite direction which is required by vendor manual.
Change in mount will require retubing."
The work plan section of the MWR stated, " change valve orientation as requested.
See maintenance planner for 3/8~ inch tubing.
No QC hold or-inspection points."
The maintenance mechanics interpreted these-statements to mean that the instrument air connections to the valve were connected in the opposite direction.
They, therefore rotated the valve to accommodate rerouting of the instrument air tubing.
They I
l did not perform any maintenance that corrected the orientation of the valve's solenoid.
Upon completion of the maintenance, the MWR was returned to the maintenance planner.
He forwarded the work package, along with several other work packages associated with the blowdown evaporator maintenance outage, to the Operations group for review.
The MWR l
was reviewed and SW-LW-61 was returned to service by Operations personnel on June 24, 1993, at the end of the blowdown evaporator maintenance outage.
There is no indication that any post-maintenance testing was performed prior to restoring SW-LW-61 to service.
The work package did, however, state that a valve cycle should be performed and that IT-72 is the post-maintenance operability test applicable to SW-LW-61.
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Following completion of the maintenance, the plant engineer responsible for solenoid valves inspected the valve to assess the adequacy of the maintenance.
He determined that the solenoid was still installed in the improper orientation.
He discussed the situation with personnel from the maintenance group.
The maintenance group determined that another MWR should be initiated to correct the condition.
This MWR was initiated on July 14, 1993.
Page 5 of 7
r On September 10, 1993, prior to performing any maintenance on
'SW-LW-61-S, IT-72 was performed to meet a periodic surveillance requirement.
At.0205, during performance of the in-service test, SW-LW-61 failed to shut, as required.
This test failure placed both units in a 48-hour Limiting Condition for Operation (LCO) in accordance with Technical Specification 15.3.3.D.2.c.
The LCO was
'i exited at 0240 when a. dedicated operator was stationed at SW-LW-61.
The Duty and Call Superintendent determined that manual action performed by a dedicated operator could be substituted for automatic action had it been necessary.
An inspection of the valve by Operations personnel determined that the instrument air to the solenoid valve was tubed incorrectly.
SW-LW-61 was correctly retubed, and the solenoid was correctly oriented, under the existing July 14, 1993 MWR and returned to-service at 1422, following the successful completion of post-maintenance testing.
In response to this event, a Human Performance Enhancement System (HPES) evaluation was performed.
The HPES evaluator determined that an inadequate work package combined with personnel error contributed to this event.
The work package was determined to be inadequate because it did not clearly describe the work that had to be performed to. reorient the i
solenoid.
The maintenance mechanics believed that the work plan directed retubing the solenoid valve to redirect the instrument air flow.
The actual intent of the MWR, however, was to correct the orientation of the solenoid.
Had the work plan been clear, this event could have been avoided.
The work package did, however, state that a valve cycle should be performed and that IT-72 is the post-maintenance operability test applicable to SW-LW-61.
l Personnel error was also determined to be a contributing factor in this event because no post-maintenance testing was performed upon completion of the maintenance.
Had testing been performed, the improper maintenance would have been immediately discovered and corrected.
Following completion of any maintenance, the MWR work a
package is forwarded to the on-shift Operations crew for review.
During this review, the responsible Operations supervisor-is required to determine if any post-maintenance testing is necessary prior to returning the equipment to service, based on the scope of I
the work performed.
If a determination is made that no testing is required, an explanation must be provided on the MWR.
In this case, however, the Operations supervisor returned the valve to service without performing any post-maintenance testing, and did not provide any explanation as to why post-maintenance testing was not required.
The responsible supervisor, when questioned, did not remember his review of the MWR work package, nor could he provide any explanation for his actions.
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' CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED FOR VIOEATION 2:
In order to emphasize the importance of post-maintenance reviews, the Manager - Operations counseled the responsible supervisor, discussing the review requirements for MWRs and the post-maintenance testing requirements for safety-related equipment.
Additionally, in order to ensure that the appropriate personnel can benefit from the lessons learned from this event, copies-of Licensee Event Report 93-008-00, "SW-LW-61 Determined to be Inoperable During Surveillance Testing," PBNP 5.17, " Standards for MWR Work Plans," and the HPES evaluation were forwarded to the department training advisory committees.
These committees have reviewed the material and have made their training recommendations to the training group at Point Beach.
Discussions were also held with the Manager - Maintenance following this event.
He stated that it is expected that maintenance planners clearly understand the problem to be corrected prior to writing any work plan.
Additionally, it is expected that the applicable maintenance supervisor review the work package prior to the performance of the maintenance.
These reviews are performed to ensure that the scope of the work is properly identified and that the work plan adequately describes the work to be performed.
In this case, both of these reviews failed to identify any problems with the work package.
In response to this event, management expectations with regard to pre-job work package reviews have been emphasized to all maintenance planners and supervisors.
CORRECTIVE ACTION TO BE TAKEN TO AVOID FURTHER VIOLATIONS:
As stated in Licensee Event Report 93-008-00 and in our response to Violation 1, we believe that the improper MWR closcout review is an isolated case and that sufficient controls are already in place.
However, in order to confirm this, we. intend to conduct a quality assurance audit of completed MWRs to verify proper closeout review with regard to post-maintenance testing.
The adequacy of work plans and their pre-job reviews will also be examined during this s
audit.
This audit will be completed by February 28, 1994.
i In response to the training recommendations made by the various training advisory committees, the training group at Point Beach is developing a computer-based training module that will be used to i
educate appropriate personnel on the various aspects of the event.
The training group anticipates having this module developed, on-line, and available for appropriate personne] by April 1, 1994.
The actual training of the appropriate personnel will therefore be completed by June 1, 1994.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED FOR VIOLATION 2:
We will be in full compliance once the quality assurance audit and the computer-based training is complete.
These items will be H
completed by June 1, 1994.
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